Provider Demographics
NPI:1306882279
Name:LEROUX, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LEROUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATWELL RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-547-3480
Mailing Address - Fax:352-392-8413
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072435L207T00000X
FLME139330207T00000X
NY196968207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F48614Medicare UPIN
PA0018351110003Medicaid
PA046098Medicare PIN